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Cholesterol Embolism Treatment & Management

  • Author: Lisa Kirkland, MD, FACP, FCCM, MSHA; Chief Editor: Vincent Lopez Rowe, MD  more...
 
Updated: Aug 10, 2015
 

Medical Care

Medical management is supportive.[12] Hemodynamic monitoring, including pulmonary artery catheterization, may be helpful for fluid and vasopressor adjustments. If acute respiratory distress syndrome (ARDS) occurs, mechanical ventilation may be required for a prolonged period. Dialysis should be started when indicated because patients can recover limited renal function. Aggressive nutritional and metabolic support is essential because these patients often lose considerable lean body mass to ongoing catabolism.

Pharmacologic therapy has not been particularly successful in patients with cholesterol embolism syndrome. Vasodilator therapy with calcium channel blockers may help relieve the local ischemia resulting from vasospasm, but angiotensin-converting enzyme (ACE) inhibitors should not be used, because of their negative effects on renal afferent arterioles and the glomerular filtration rate.

Patients presumed to have vasculitis have been treated with high-dose steroids and anti-inflammatory agents, with anecdotal reports of recovery. However, steroids may predispose patients to infectious, metabolic, and nutritional complications and difficulties with wound healing. In a report of four cases of cholesterol embolism after cardiac catherization that were associated with deteriorating renal function, low-dose (0.3 mg/kg/day) corticosteroid therapy yielded improved renal function in three of the four patients.[13]

The use of anticoagulants is controversial because anticoagulants and thrombolytics have been shown to induce atheroemboli. Anecdotal reports of treatment with apheresis, iloprost, statin, colchicine, or combinations of these drugs with steroids report improvement in some cases.[14, 15, 16, 17, 18]

Further invasive vascular procedures and anticoagulant or thrombolytic therapies should be avoided. If such treatments are unavoidable, downstream protection devices to trap atheromatous debris after stenting or angioplasty are suggested.[19]

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Surgical Care

Surgical therapy (eg, aortic aneurysm resection) may be necessary to remove the source of atheroembolic material. Stent-grafting may be a less invasive method to reduce risk of embolization.[20]

Damaged tissue should be protected and allowed to demarcate for several months. Surprisingly, a majority of the damaged area may recover. Necrotic tissue should be debrided, and establishing vascular access for dialysis also may be necessary.

In severe cases, lumbar sympathetic block (rarely, surgical sympathectomy) has been used to avoid impending lower-extremity tissue loss resulting from intense vasoconstriction.

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Prevention

If an invasive radiologic procedure is necessary, the risk of inducing cholesterol embolism must be considered. If the patient is at high risk, with known or suspected severe aortic atherosclerosis or aortic aneurysm, the Judkins (ie, brachial) approach or a radial artery approach may be used for introducing the catheter into the aorta. However, some investigators found that the approach made no difference, leading them to suspect the ascending aorta as a major source of atheroemboli.

Gentle handling of the severely diseased aorta during cardiac or aortic surgery can reduce the risk of cholesterol embolism. Careful clamping techniques and careful selection of aortotomy sites may minimize disruption of the atherosclerotic plaque.

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Consultations

The following consultations should be considered as indicated:

  • Nephrologist
  • Critical care specialist
  • Metabolic and nutritional support specialists
  • General surgeon, vascular surgeon, or both
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Contributor Information and Disclosures
Author

Lisa Kirkland, MD, FACP, FCCM, MSHA Assistant Professor, Department of Internal Medicine, Division of Hospital Medicine, Mayo Clinic; Vice Chair, Department of Critical Care, ANW Intensivists, Abbott Northwestern Hospital

Lisa Kirkland, MD, FACP, FCCM, MSHA is a member of the following medical societies: American College of Physicians, Society of Hospital Medicine, Society of Critical Care Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Travis J Phifer, MD 

Travis J Phifer, MD is a member of the following medical societies: American College of Emergency Physicians, American College of Surgeons, American Medical Association, Association for Academic Surgery, Society for Academic Emergency Medicine, Society for Vascular Surgery, Society of Critical Care Medicine

Disclosure: Nothing to disclose.

Chief Editor

Vincent Lopez Rowe, MD Professor of Surgery, Program Director, Vascular Surgery Residency, Department of Surgery, Division of Vascular Surgery, Keck School of Medicine of the University of Southern California

Vincent Lopez Rowe, MD is a member of the following medical societies: American College of Surgeons, American Heart Association, Society for Vascular Surgery, Vascular and Endovascular Surgery Society, Society for Clinical Vascular Surgery, Pacific Coast Surgical Association, Western Vascular Society

Disclosure: Nothing to disclose.

References
  1. Oe K, Araki T, Nakashima A, Sato K, Konno T, Yamagishi M. Late onset of cholesterol crystal embolism after thrombolysis for cerebral infarction. Intern Med. 2010. 49(9):833-6. [Medline]. [Full Text].

  2. Higo S, Hirama A, Ueda K, Mii A, Kaneko T, Utsumi K. A patient with idiopathic cholesterol crystal embolization: effectiveness of early detection and treatment. J Nippon Med Sch. 2011. 78(4):252-6. [Medline].

  3. Jucgla A, Moreso F, Muniesa C. Cholesterol Embolism: Still an Unrecognized Entity with a High Mortality. J Am Acad Derm. 2006. 55:786-793.

  4. Willens HJ, Kramer HJ, Kessler KM. Transesophageal echocardiographic findings in blue toe syndrome exacerbated by anticoagulation. J Am Soc Echocardiogr. 1996 Nov-Dec. 9(6):882-4. [Medline].

  5. Fukumoto Y, Tsutsui H, Tsuchihashi M, Masumoto A, Takeshita A,. The incidence and risk factors of cholesterol embolization syndrome, a complication of cardiac catheterization: a prospective study. J Am Coll Cardiol. 2003 Jul 16. 42(2):211-6. [Medline].

  6. Acarturk E, Ozeren A, Sarica Y. Detection of aortic plaques by transesophageal echocardiography in patients with ischemic stroke. Acta Neurol Scand. 1995 Aug. 92(2):170-2. [Medline].

  7. Adler Y, Shohat-Zabarski R, Vaturi M, Shapira Y, Ehrlich S, Jortner R. Association between mitral annular calcium and aortic atheroma as detected by transesophageal echocardiographic study. Am J Cardiol. 1998 Mar 15. 81(6):784-6. [Medline].

  8. Katz ES, Tunick PA, Rusinek H, Ribakove G, Spencer FC, Kronzon I. Protruding aortic atheromas predict stroke in elderly patients undergoing cardiopulmonary bypass: experience with intraoperative transesophageal echocardiography. J Am Coll Cardiol. 1992 Jul. 20(1):70-7. [Medline].

  9. Ribakove GH, Katz ES, Galloway AC, Grossi EA, Esposito RA, Baumann FG. Surgical implications of transesophageal echocardiography to grade the atheromatous aortic arch. Ann Thorac Surg. 1992 May. 53(5):758-61; discussion 762-3. [Medline].

  10. Tenenbaum A, Garniek A, Shemesh J, Fisman EZ, Stroh CI, Itzchak Y. Dual-helical CT for detecting aortic atheromas as a source of stroke: comparison with transesophageal echocardiography. Radiology. 1998 Jul. 208(1):153-8. [Medline].

  11. Manganoni AM, Venturini M, Scolari F, Tucci G, Facchetti F, Graifemberghi S. The importance of skin biopsy in the diverse clinical manifestations of cholesterol embolism. Br J Dermatol. 2004 Jun. 150(6):1230-1. [Medline].

  12. Belenfant X, Meyrier A, Jacquot C. Supportive treatment improves survival in multivisceral cholesterol crystal embolism. Am J Kidney Dis. 1999 May. 33(5):840-50. [Medline].

  13. Masuda J, Tanigawa T, Nakamori S, Sawai T, Murata T, Ishikawa E, et al. Use of corticosteroids in the treatment of cholesterol crystal embolism after cardiac catheterization: a report of four Japanese cases. Intern Med. 2013. 52 (9):993-8. [Medline].

  14. Elinav E, Chajek-Shaul T, Stern M. Improvement in cholesterol emboli syndrome after iloprost therapy. BMJ. 2002 Feb 2. 324(7332):268-9. [Medline]. [Full Text].

  15. Hasegawa M, Sugiyama S. Apheresis in the treatment of cholesterol embolic disease. Therap Apher Dial. 2003 Aug. 7(4):435-8. [Medline].

  16. Verneuil L, Ze Bekolo R, Dompmartin A, Comoz F, Marcelli C, Leroy D. Efficiency of colchicine and corticosteroids in a leg ulceration with cholesterol embolism in a woman with rheumatoid arthritis. Rheumatology (Oxford). 2003 Aug. 42(8):1014-6. [Medline].

  17. Sevillano-Prieto ÁM, Hernández-Martínez E, Caro-Espada J, Molina-Gómez M, Gutiérrez-Martínez E, Morales-Ruiz E, et al. Cholesterol atheroembolism and combined treatment with steroids and iloprost. Nefrologia. 2012. 32 (6):824-8. [Medline].

  18. Sanai T, Matsui R, Hirano T. LDL apheresis for cholesterol embolism following coronary artery bypass graft surgery--a case report. Angiology. 2006 May-Jun. 57(3):379-82. [Medline].

  19. Lowe HC, Houser SL, Aretz T, MacNeill BD, Oesterle SN, Palacios IF. Significant atheromatous debris following uncomplicated vein graft direct stenting: evidence supporting routine use of distal protection devices. J Invasive Cardiol. 2002 Oct. 14(10):636-9. [Medline].

  20. Carroccio A, Olin JW, Ellozy SH, Lookstein RA, Valenzuela R, Minor ME. The role of aortic stent grafting in the treatment of atheromatous embolization syndrome: results after a mean of 15 months follow-up. J Vasc Surg. 2004 Sep. 40(3):424-9. [Medline].

  21. Brown PJ, Zirwas MJ, English JC 3rd. The purple digit: an algorithmic approach to diagnosis. Am J Clin Dermatol. 2010. 11(2):103-16. [Medline].

  22. Frank RD, Velden J. Images in clinical medicine. Cholesterol emboli after coronary bypass surgery. N Engl J Med. 2011 Jan 20. 364(3):265. [Medline].

  23. Hirano Y, Ishikaw K. Cholesterol Embolization Syndrome: How to Recognize and Prevent This Potentially Catastrophic Iatrogenic Disease. Int Med. 2005. 44:1209-1210.

  24. Keen RR, McCarthy WJ, Shireman PK, Feinglass J, Pearce WH, Durham JR. Surgical management of atheroembolization. J Vasc Surg. 1995 May. 21(5):773-80; discussion 780-1. [Medline].

  25. Kirkland L. Cholesterol embolism in intensive care patients. J Intensive Care Med. 1993. 7(3):12-21.

  26. Kolh PH, Torchiana DF, Buckley MJ. Atheroembolization in cardiac surgery. The need for preoperative diagnosis. J Cardiovasc Surg (Torino). 1999 Feb. 40(1):77-81. [Medline].

  27. Kronzon I, Saric M. Cholesterol embolization syndrome. Circulation. 2010 Aug 10. 122(6):631-41. [Medline].

  28. Maki T, Izumi C, Miyake M, Izumi T, Takahashi S, Himura Y, et al. Cholesterol embolism after cardiac catheterization mimicking infective endocarditis. Intern Med. 2005 Oct. 44(10):1060-3. [Medline].

  29. Resnik KS. Intravascular cholesterol clefts as an incidental finding: cholesterol embolism or not?. Am J Dermatopathol. 2003 Dec. 25(6):497-9. [Medline].

  30. Vayssairat M, Chakkour K, Gouny P, Nussaume O. Atheromatous embolisms and cholesterol embolisms: medical treatment [French]. J Mal Vasc. 1996. 21 Suppl A:97-9. [Medline].

 
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